Hindawi

Journal of Environmental and Public Health

Volume 2020, Article ID 7453027, 6 pages
https://doi.org/10.1155/2020/7453027

Research Article
Assessment on CPR Knowledge and AED Availability in Saudi
Malls by Security Personnel: Public Safety Perspective

Samer A. Al Haliq ,1 Omar M. Khraisat,2 Mohamed A. Kandil,1 Mohammed A. Al Jumaan,1

Faris M. Alotaibi,1 Fahad S. Alsaqabi,1 Hussain M. Alajmi,1 Hany A. Ellouly,1
Mahmoud A. Al-Haliq,3 Abdullah Alkhawaldeh,4 Mohammed ALBashtawy,5
and Sawsan H. Abuhammad6
1
Department of Emergency Medical Care, Imam Abdulrahman Bin Faisal University, Dammam 31441/1982, Saudi Arabia
2
Department of Nursing, Al-Ahliyya Amman University, Amman 19328, Jordan
3
Department of Coaching and Sport Management, Hashemite University, Zarqa 13115/591504, Jordan
4
Department of Nursing, Jerash University, Jerash 26150/130, Jordan
5
Department of Nursing, Al Al-Bayt University, Mafraq 25113/130040, Jordan
6
Department of Nursing, Jordan University of Science and Technology, Irbid 22110/3030, Jordan

Correspondence should be addressed to Samer A. Al Haliq; saalhaliq@iau.edu.sa

Received 31 January 2020; Accepted 10 March 2020; Published 13 April 2020

Academic Editor: Stefano Capolongo

Copyright © 2020 Samer A. Al Haliq et al. This is an open access article distributed under the Creative Commons Attribution
License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is
properly cited.

Security personnel are the first ones who attend the scene in the case of out-of-hospital cardiac arrest (OHCA) at malls.
Cardiopulmonary resuscitation (CPR) is not enough for those patients; they need an automated external defibrillator (AED) to
bring the heart to function normally. This study aimed to assess the current status of CPR and AED knowledge and availability in
Saudi malls by security personnel. Using a descriptive design, a study was conducted at seven malls located in the Eastern Province
of Saudi Arabia. Two hundred and fifty participants were surveyed using the American Heart Association (AHA) 2015 guidelines
to assess CPR and AED knowledge and availability in Saudi malls. The sample mean age was 32.60 years (SD � 10.02), and 87% of
participants were working as security personnel. The majority of the participants had not received training about CPR and AED
(75.8% and 95.2%, respectively). Common misconceptions are fallen into all categories of CPR and AED knowledge. Correctly
answered statements ranged from 7.2% in the compression rate to 24.2% in hand placement. The study results indicated a poor
training knowledge of CPR and AED in public settings. Integrating high-quality CPR and AED knowledge within the school and
college curricula is a vital need. However, in order to maximize the survival rate, it is important to set laws and legislation adopted
by stakeholders and decision makers to advocate the people who try to help, mandate AED installation in crowded places, and
mandate teaching hands-only CPR and AED together as a package.

1. Introduction survived to hospital discharge [3]. In Saudi Arabia, the

Cardiovascular disease is a leading cause of worldwide
mortality, accounting for approximately 17 million deaths
yearly [1]. Approximately 50 to 110 per 100,000 out-of-
hospital cardiac arrest (OHCA) annual incidence occurs in
the United States and Europe populations [2, 3]. In the
United States, only 10.4% of OHCA who had received re-
suscitation from Emergency Medical Services (EMS)
cardiovascular disease mortality rate is 37% according to the
World Health Organization (WHO) statistics [4]. A study
conducted in Riyadh city in Saudi Arabia reported a high
mortality rate of 95.8% among adult OHCA patients; this
study reported that poor training of cardiopulmonary
pulmonary resuscitation (CPR) and nonutilization of an
automated external defibrillator (AED) might be the major
factors that stand behind the OHCA high mortality rate [5].
2 Journal of Environmental and Public Health
Similarly, the study which was conducted among non-
medical individuals in 2018 at Jeddah city, the second largest
city in Saudi Arabia, revealed that the participants perceived
a lack of knowledge regarding CPR [6].
Emergency Cardiovascular Care (ECC) 2020 impact
goals focus on and set an ambitious target to double the
cardiac arrest survival rates and out-of-hospital community
response [7, 8]. The community forms the first three links
(recognition and activation of the emergency response
system, immediate high-quality CPR, rapid defibrillation,
basic and advanced EMS, advanced life support, and
postarrest care) of the American Heart Association (AHA)
to improve the survival rates of adult chain of survival of
OHCA [9–11].
The chain of survival can be improved through activating
the community by increasing the public awareness regarding
the importance of early defibrillation [10, 12–14]. The AHA
Highlights 2017 recommendations support the community
hands-only CPR training to be performed for OHCA adult
victims [10]. CPR alone is not enough, and the AEDs are
important to restore the normal sinus rhythm and to bring
the heart to function normally [12, 15]. Early CPR and AED
utilization by the community may assist in life saving, and it
is associated with a two- to three-fold increase in survival
when compared to victims who had no CPR and AED before
the EMS arrival [9, 13, 16]. Additionally, for most victims,
AED is not offered until the EMS crews reach the scene, and
for every minute delay in defibrillation, the chances of
survival decline by 10%, so familiarity with the public access
defibrillation (PAD) may enable rapid defibrillation before
EMS arrival [17].
Despite the efforts to focus on the utilization of AED,
there are still a lot of AED issues; research suggests that the
community faces challenges regarding the utilization of
AEDs [18]. Moreover, the community is afraid from AEDs
that might be dangerous, complicated technically, and dif-
ficult to use because of their limited knowledge and fa-
miliarity with them [19].
In Saudi Arabia, 2030 Royal vision was built around
three themes: a vibrant society, a thriving economy, and an
ambitious nation. A vibrant society is supported by an
empowering social and health care system. The security
person is the first one who attends the scene in the case of
OHCA at malls. Thus, this study aimed to assess the need for
AED public access that might empower the health care
system and help support community safety regarding ECC
in public settings following 2030 vision. Specifically, the
study aimed to assess the current status of CPR and AED
knowledge and availability in Saudi malls by security
personnel.
2. Materials and Methods
2.1. Study Design, Sample, and Setting. A descriptive design
was used to assess the current status of CPR and AED
knowledge and availability in Saudi malls by security
personnel.
The study was conducted over a period of six months in
seven major malls located in Dammam and AL Khobar,
Eastern Province of Saudi Arabia. The inclusion criteria for
this study were all employees in the selected malls, namely,
the security guards and administrators who were able to
understand written Arabic.
The estimated sample size was calculated using the
Power Primer (Cohen, 1992). The test revealed that using a
desired power of 0.80, medium effect size (r � 0.25), and 0.05
level of significance, the estimated sample size was 200 mall
staff. Oversampling was utilized to gain increased under-
standing and to overcome participant attrition. Thus, 250
mall employees were selected to participate in the study.
2.2. Instruments. The study utilized anonymous self-re-
ported questionnaire. The questionnaire had been designed
according to the 2015 AHA guidelines and 2017 AHA
Highlights, and it was adapted to be used in this study. This
questionnaire was utilized by many studies to assess the
public knowledge of adult CPR and effective use of AED
[10, 11, 15]. The questionnaire was translated and back
translated by bilingual PhD holders. A pilot study was
conducted to evaluate the clarity and appropriateness of the
questionnaire to the Saudi Arabian culture.
The questionnaire included two parts. Part one is a
demographic data sheet that includes questions designed to
elicit information about participants’ demographic charac-
teristics, such as their age, gender, level of education, job
title, whether they have received CPR and AED training or
not, additional questions regarding information about the
source of CPR and AED training, witnessing cardiac arrest
cases while working, and AED device availability in the
workplace. The second part includes statements to assess the
knowledge of adult CPR and AED utilization. It includes
whether or not they know the EMS number in Saudi Arabia,
steps of CPR performance (depth, rate, hand placement, and
compression-ventilation ratio), and the universal steps of
AED operation.
2.3. Pilot Study. A pilot study was conducted at one of the
selected malls to test the instrument’s psychometric prop-
erties, the time required to complete the questionnaire, and
its clarity. Twenty participants completed the questionnaire
within 5–15 minutes. The psychometric evaluation of the
English version of the questionnaire was evaluated by
content validity. However, the internal consistency of the
questionnaire was measured using Cronbach’s alpha (α)
coefficient. Reliability revealed an alpha coefficient of 0.71.
2.4. Ethical Considerations. A standard code of ethics for
participants and the requirements of the Institutional Re-
view Board (IRB) were followed. The study adheres to the
“Guidelines for Ethical Research Practice” and was approved
by advisory board from the research committee at the
university (IRB: 2019-03-155). The study package included
an introductory letter explaining the purpose of the study.
The participants were informed that their participation was
voluntary, they have the right to withdraw from the study at
any time without penalty, and that all the information
Journal of Environmental and Public Health 3

obtained would be treated confidentially and anonymously. Table 1: The demographic features of the participants.
A consent form was attached to the questionnaire. All Characteristics Result
questionnaires and study materials were kept in a secured
Mean 32.60 years
cabinet in the principal investigator’s office. Age
(SD 10.02)
Gender
2.5. Data Collection and Procedures. Approval to conduct Male 178 (86%)
the study was obtained from the IRB at the university. Data Female 29 (14%)
were collected from March 1 to August 30, 2019. Permission Level of education
was also obtained from the Malls’ administration. The Less than secondary education 56 (27.1%)
participants were approached in the work setting, and the Secondary education 111 (53.6%)
questionnaire was distributed at the end of the work. The College education 21 (10.1%)
University education 19 (9.2%)
researchers and the administration decided when and how
to approach possible participants. Participants were in- Job title
formed about the purposes of the study. They were provided Administrator 27 (13%)
Security personnel 180 (87%)
with the questionnaire along with a cover letter.
Receive any training covering CPR
Yes 50 (24.2%)
2.6. Data Analysis. The data were coded using the SPSS No 157 (75.8%)
version 21 (SPSS, Inc., Chicago, IL, USA). Data were Receive any training covering AED
screened for missing data and outliers. No missing values Yes 10 (4.8%)
and outliers were found. To meet the study aim, descriptive No 197 (95.2%)
statistics was applied to data. Source of CPR and AED training
Web/computer 4 (1.9%)
3. Results and Discussion Accredited CPR course 20 (9.7%)
Training books/written materials 1 (0.5%)
3.1. Demographic Data. A total of 250 questionnaires were Video presentation 1 (0.5%)
distributed; 207 (82.8%) were returned. The features of the Didactic lecture 8 (3.9%)
participants are displayed in Table 1. Internal institute training 16 (7.7%)
Witness cardiac arrest cases while working
Yes 22 (14%)
3.2. CPR and AED Training Status. A majority of 157 No 178 (86%)
(75.8%) participants reported having received no training AED device availability in workplace
about CPR. Of all those 20 (9.7%) who were CPR trained, Yes 0 (0%)
10 (4.8%) of them included AED training. However, 197 No 207 (100%)
(95.2%) of the participants reported having received no SD � standard deviation; CPR � cardiopulmonary resuscitation;
training about AED. In addition, 207 (100%) of the par- AED � automated external defibrillator.
ticipants reported that the AED device is not available in all
working areas, with 14% of the participants stating that
participants of female security personal accepted to par-
they had previously witnessed sudden cardiac arrest as
ticipate in the study. Also, the findings of the study showed
described in Table 1.
that the majority of the participants have a secondary level of
education, and the rate of participants who received no CPR
3.3. Knowledge about CPR and AED. In Table 2, the top training was displayed to be 75.8%. As well as, the partic-
misconceptions (fallacies) about the knowledge of adult CPR ipants who received no AED training were found to be 95.2%
and AED among participants are presented. It is clear that as shown in Table 1.
participants’ most common misconceptions are not limited Different countries have conducted several studies in
only to one aspect of CPR performance or AED, but fall into their societies to assess the knowledge and awareness re-
all main categories: the compression-ventilation ratio garding CPR and AED utilization [6, 14, 20–26]. CPR
(90.8%), the adult compression rate (92.8%), the adult training rates in other countries were as follows: in the
compression depth (84.5%), the hand placement in adult western region at Jeddah in Saudi Arabia (28.7%) [6] and a
CPR (75.8%), and the universal steps of AED operation similar rate (29%) in Jordan [21]. Additionally, 21% in Hong
(92.3%). In addition, more than half of the participants Kong [24], 35% in Japan [14], 74% in New Zealand [26], 75%
(54.1%) did not know the correct EMS number in Saudi in Poland [27], 79.3% in Washington [25], 68% in Australia
Arabia. [23], in Sweden 45% [22], and 40.3% in Turkey [20]. This can
This study aimed to assess the current status of CPR and be explained by the fact that it is obligatory to have CPR
AED knowledge and availability in Saudi malls by security training by the law of Occupational Health and Safety in
personnel. The findings of the study showed that the ma- these countries [6, 14, 20–25].
jority of the (86%) participants were male; culturally, gender In Saudi Arabia, the Saudi Heart Association (SHA)
equality of ease of access to resources and job opportunities and AHA have taken the responsibility of delivering
was still limited in Saudi Arabia, which is explained by a few accredited CPR and AED courses. However, unaccredited
4 Journal of Environmental and Public Health

Table 2: Descriptive results of participant’s answers on the knowledge of adult CPR and AED.
Item participants answers
Item Question Correct Wrong
Frequency (%) Frequency (%)
The EMS number in Saudi Arabia is? (TB)
1 (A) 996 95 (45.9) 112 (54.1)
(B) 997
The adult compression-ventilation ratio for 1 or 2 rescuers is? (TB)
2 (A) 15 : 2 19 (9.2) 188 (90.8)
(B) 30 : 2
The adult compression rate is? (TB)
3 (A) 80–100/min 15 (7.2) 192 (92.8)
(B) 100–120/min
The adult compression depth is? (TA)
4 (A) At least 2 inches (5 cm) 32 (15.5) 175 (84.5)
(B) Less than 2 inches (5 cm)
The hand placement in adult CPR is? (TA)
5 (A) Two hands on the lower half of the breastbone (sternum) 50 (24.2) 157 (75.8)
(B) Two hands on the middle of the breastbone (sternum)
When the AED device arrives, what should you do next? (TB)
6 (A) Attach pads, power on, analyze and follow AED prompts 16 (7.7) 191 (92.3)
(B) Power on, attach pads, analyze and follow AED prompts
EMS � Emergency Medical Services; TA � true choice A; TB � true choice B; CPR � cardiopulmonary resuscitation; AED � automated external defibrillator.

CPR and AED courses were delivered through lectures,
video presentation, workshops, and internal institute
training. The results indicated that CPR and AED training
might be primarily delivered through unaccredited CPR
and AED courses as evidenced in Table 1, and that 14% of
participants stated that they had previously witnessed
sudden cardiac arrest. Similarly, 15.8% at Jeddah in Saudi
Arabia [6], 18.6% in Turkey [20], 19% in Japan [14], and
23.3% in Jordan [21]. Most of the participants witnessed
sudden cardiac arrest without performing CPR; this can be
explained by the fact that the participants are hesitant to
apply CPR and AED universal steps since they do not have
enough knowledge to perform CPR and AED effectively
[6, 14, 20, 21]. They are also afraid to make a mistake
particularly with no AED device available in their work-
place [19]. Many studies explained that poor availability,
adequacy, distribution of AED, and training might be
major factors that stand behind the OHCA high mortality
rate [5, 6, 14, 21].
Recognition and activation of the emergency response
system is the first link of adult chain of survival of OHCA;
however, it is important to know the local EMS number
[9–11]. The results indicated that more than half of the
participants (54.1%) did not know the correct EMS number
in Saudi Arabia. This might refer to the utilization rate of
EMS services in Saudi Arabia was very low in comparison to
other countries and states [28].
Quality of CPR concepts were evaluated: compression
depth and rates and hand placement. The rates were found to
be significantly higher in participants who received CPR
training than in those who did not receive CPR training. The
results indicated that the participants held a considerable
number of misconceptions about CPR and AED utilization,
and they had insufficient knowledge about the core and
principles of CPR and AED universal operation steps. These
results are partially consistent with previous studies with regard
to poor knowledge of CPR and AED utilization
[5, 6, 20, 21, 24, 26, 29]. However, some aspects were different
in Saudi Arabia. This might refer to the status of CPR and AED
utilization, and the structured community safety programs for
CPR and AED awareness and public access are not available in
Saudi Arabia. On top, CPR and AED services are limited to
some hospitals as training courses. Further research to examine
the availability, adequacy, distribution, and need of CPR and
AED training in Saudi Arabia is strongly recommended.
Another explanation for the poor knowledge of CPR and AED
could be the lack of education content about it in school and
college curricula. However, in other countries, it is obligatory to
have CPR and AED courses before driving license and they are
integrated into secondary schools curricula in some courtiers
such as Austria, Japan, Norway, Hong Kong, and Singapore
[14, 20, 23–25].
3.4. Limitations. Considering the importance of the studied
issue, the study involved a small sample of security personnel
from seven malls only, and the findings may not be rep-
resentative of the status of CPR and AED knowledge among
security personnel in other settings.
Moreover, the use of a self-report questionnaire could
introduce bias, in that participants might not always give full
descriptions of their CPR and AED training experience.
Also, this study was limited to one area located in the Eastern
Province of Saudi Arabia, which limits the external validity
of the findings. Future research should include additional
studies with a larger sample size recruited from other
community settings such as airports, mosques, and football
stadiums.
Journal of Environmental and Public Health
4. Conclusions
The results of this study show that participants have in-
sufficient knowledge about adult CPR and AED universal
operation steps. This study indicates the importance of
generalizing CPR and AED training to the public; by this
means, the rate of witnesses who start CPR can be raised.
Moreover, laws and legislation should set an effective
practical system supporting CPR and AED training in the
public settings, mandate AED installation in crowded places,
and teach hands-only CPR and AED together as a package to
improve the survival rate and enhance public safety.
Thus, integrating high-quality CPR and AED knowledge
within the school and universities curricula is a vital need.
More descriptive studies are still needed to gain a com-
prehensive understanding of the outcomes of CPR and AED
training in Saudi community settings.
Data Availability
The datasets used and/or analyzed during the current study
are available from the corresponding author on reasonable
request.
Conflicts of Interest
The authors declare that there are no conflicts of interest
regarding the publication of this paper.
Acknowledgments
The authors would like to acknowledge all individuals who
participated in this study. The authors would also like to
thank Imam Abdulrahman Bin Faisal University, for sup-
porting them in this research.
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